A comprehensive and thorough examination of a surgical patient is a prerequisite for making the definitive diagnosis. The purposes of the preoperative diagnostic workup are therefore as follows:
1) to define the organ affected;
2) to find out the aetiology and pathogenesis of the disease;
3) to identify the complications, if any, of the condition.
It is noteworthy that the results of each of the three stages do influence the therapeutic plan.
All the pertinent findings, both positive and negative, of physical examination and laboratory investigations are to be recorded in the patient's medical record. This is a document with medical, research and legal purposes; thus it should be written clearly, accurately and be free of non-conventional abbreviations.
A standard outline for history-taking and physical examination in surgery, alongside with specific patterns, whenever necessary, follows.
The chief complaints in detail, history of the present illness, as well as results of the comprehensive physical examination with an emphasis on the organ(s) affected (Latin status localis) are the mainstays of the patient's medical record.
Taking the medical history. Trying to find out the patient's life events associated with the problem that has made them seek out the medical aid, the physician will interview the patient in a standardised sequence. Putting questions in simple nontechnical words is a prerequisite as this ensures that the patient understands what he/she is meant to talk about. The chief purpose of the history to furnish clues for diagnosis, which implies that only relevant data are to be considered seriously. The value of interrogation can be sometimes undermined when the patient is not able to present the complaints well and explain the chief complaints despite the fact that the question has been put correctly.